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• APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERHIJ EXPIRES- 1 YEAR FROG DATE ED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4110 Industrial Way City Tram Lot Size/Acreage — acres Owner's Name McKesson_D ariv_ _ Address One- Post St__ SFr CA 9410.4. Phone5-983-2598 209 Contractor SnP� rtrr�Exnl arab nn AddresQR25 F, Mf zrtl Sr_azkt 7n,License No.�_ 151 226 Phone — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 3 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ra SEWER LINES /,0+ ft DISPOSAL FLD.na PROP. LINE lA- ft FOUNDATION 40+ ft AGRICULTURE WELL Ra— OTHER WELL 2000+ fPITS/SUMPS na INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation h Jnrh Dia. of Well Casing i..l Domestic/Private Q Gravel Pack k7 Tracy Type of Casing_. 121.1C sch 40 Specifications I'1 Public 1-1 Other 171 Delta Depth of Grout Seal f,rl 1 rlppt— Type of Grout rAmAnt/ben t�or ite i I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done, Well Destruction JJ Well Diameter 2 ingh Sealing )Material & Depth cement bentonite grout over full Depth 21 feet Filler Material & Depth depth (21 feet) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is `• available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms, 7 Character of soil to a depth of 3 feet: � Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/siva FILTER BED ❑ Distance to nearest: Well \011ndation Property Line SEEPAGE PITS I i Depth Size _ Number SUMPS Lt Distance to ne est: Well Foun tion Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant.,ftst call If r II required nspections. Complete drawing gA verse side. /� C Signed X Title: �Gr [ l,oeeV Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area. �.L� 2— Pit Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA8H RECEIVED BY r_ DATE �/y; }�PERMIT'NO. 9 • EH 14.241REY.iiNS1 i 5 EH 1t•.M "ii�� lQ